Wellbeing Services - Anxiety Busting Booklet

Anxiety Busting

Helping yourself to reduce your anxiety

By Jenny Cadman, Sarah Lane and Josie Bannon

It can be hard to ask for help when you are feeling anxious. It can feel as though you are the only one struggling and that everyone else is doing fine. Well done in taking the first step towards tackling the problem and reducing your anxiety!

This booklet is aimed at any student who struggles with anxiety. It includes a student example to illustrate different ideas and techniques. All the techniques in the booklet are based on the Cognitive Behavioural Therapy (CBT) approach, which we will discuss in more detail further on in this booklet. There is a lot of research that shows that CBT can be very helpful for reducing anxiety. You may be working through the booklet on your own, as part of the Anxiety Busting course, or one to one with the support of a practitioner from the

Wellbeing Centre. It can also be helpful to talk to someone you trust, such as a family member or a friend, who can support you through this process.

You will be able to talk through how you have got on using the different techniques and any problems that may have arisen with your practitioner.

Tackling anxiety can be a difficult and challenging process and there may be times when you feel as though you aren’t getting anywhere. Just remember that we all have good days and bad days so try not to let the bad days feel as though you have taken one step forwards and two steps back.

CBT techniques can seem difficult at first but much like exercise, the more you use them the easier they become, until you get to the point where they don’t seem like any effort at all. Again, like exercise it is also important to keep up with these techniques as much as possible so they become more of a habit and feel more natural to use.

The idea of this booklet is to give you the information you need to help yourself tackle anxiety. This means that you need to have a go at all the techniques to find out which ones are the most helpful for you.

About anxiety

Everyone feels anxious from time to time, and a certain level of anxiety is normal and even beneficial as it makes us pay attention to situations that may be dangerous.

Anxiety becomes a problem when it is persistent and impacts on your day to day life.

Types of anxiety:

Panic attacks

Social anxiety

Presentation anxiety

Obsessive compulsive disorder (OCD)

Agoraphobia

(a fear of not being able to get to somewhere safe)

Generalised anxiety

(worrying a lot about different things, always feeling tense and on edge)

Post traumatic stress disorder (PTSD)

Specific phobias

Stress

Why we have anxiety

Anxiety is something which has evolved out of human experience as a physical response to danger. It can range from a slight feeling of nervousness to an extreme sense of panic or sheer terror. This is why it feels so unpleasant: anxiety tells us that there is something dangerous to pay attention to.

Symptoms of anxiety

Worry

It is normal to worry sometimes, however when this worry is frequent and excessive it becomes a problem. Common thoughts include worrying about ‘what ifs,’ thinking that something bad is going to happen and feeling as though you can’t control your worrying.

Problems with concentration

Many people find that they have problems concentrating. This could affect things like reading, writing, talking to others or watching TV. Some people can find they can go over the same paragraph again and again and still not take in the meaning. Some people also find that they have trouble with their short term memory.

Physical anxiety

People often experience physical symptoms when they feel anxious. This can include feeling hot and flushed, an increased heart rate, feeling on edge and being unable to relax. It can even include panic and feeling as though something terrible is going to happen, or a general feeling of dread.

Sleep problems

There are a range of problems people can experience with sleep, including trouble getting to sleep, trouble staying asleep, or waking up too early. On the other hand some people sleep too much, either for longer periods or during the day.

Feeling overly tired or fatigued

This may or may not be to do with how much sleep you are getting. People often describe feeling drained of energy and say that they wake up tired.

Changes in appetite

Some people find that they have no appetite at all and struggle to eat, whereas others find that they eat more than they normally would.

Not everyone who is anxious will experience all of these symptoms. People will vary in what they experience when they have anxiety.

What is affected by anxiety

Thoughts

Thoughts are often negative or unhelpful, such as predicting the worst. People often start to worry a lot about situations and may have thoughts such as ‘What if…’

Physical symptoms

This can include feeling on edge or tense, an increased heart rate, problems with concentration, or becoming irritable.

Behaviour

People may put things off because they seem too difficult, or avoid situations altogether. They may fidget, or rely on the use of safety behaviours, which we will discuss further on in this booklet.

The above diagram shows how you can get trapped in a vicious cycle that can be very difficult to break out of.

All of these areas can be affected by anxiety and each area can start to have additional ‘knock on’ effects on the other areas. If you are worrying all the time it’s likely you will struggle to sleep and you may feel tense and on edge. As a result you might start to put off doing the things that are making you feel anxious. However this can cause the pressure to build up, leading you to worry more and to feel more anxious.

How does anxiety affect you?

Have a go at filling in your vicious cycle.

Physical symptoms

Thoughts

Behaviours

The techniques in this booklet are based on the idea of this vicious cycle. Because all of the areas combine to form the cycle it is possible to tackle anxiety by focusing on any one specific area. The booklet includes techniques focusing on thoughts and behaviours as a way of breaking the cycle. This is where the term ‘Cognitive Behavioural Therapy’ comes from.

FYI: ‘Cognitive’ refers to processes such as thoughts, memories, and attention.

Setting yourself goals to work towards...

It can be really helpful to think about what you would like to achieve from this process. What sorts of things have you stopped doing since you started to feel anxious? What would you imagine yourself doing more of if you were feeling better?

Circle how easily you think you can achieve this base on how you feel today: 0 (not at all) to 6 (anytime). When writing these goals think about whether you would be able to achieve them in a few months time. We will then revisit these each session to see if you are getting any closer to your goal. See the next page for information on how to set your goals.

GOAL ONE: Today’s date:

GOAL TWO:

Sally’s story...

Sally is in her first year at the University of Exeter and is studying English. She had a small group of close friends at college but knows no one in Exeter.

She worries a lot about making friends and what the people she hangs out with think of her. She feels very on edge in social situations: her heart races and her hands get really sweaty. She has started to avoid crowds and big social situations and makes excuses to her friends. She also stays away from crowded areas like the Forum and the town centre. She has started to worry that there is something wrong with her as everyone else seems to be managing fine.

Sally initially set herself a goal to feel calmer, however it is difficult to measure this. Making SMART goals can help.

Specific – Be as clear as you can. You may want to ‘feel less anxious’ but ask yourself what ‘feeling less anxious’ means you will be able to do e.g. go to the pub with friends.

Measurable – How will you know when you have achieved this goal? Is there an end point?

Achievable – It needs to be something you are able to achieve in the time frame, as otherwise it will seem too daunting or overwhelming. People who set goals that are too big can feel like they have failed when they can’t achieve them. It is better to start small and build up. Is your goal a small enough step?

Relevant – It needs to be relevant to you; it should match your values.

Time bound – You should have a clear idea of when you want to achieve this goal by.

To be able to go out to the pub on a Friday or Saturday night with a group of friends

Why do we experience anxiety?

It is important to remember that all humans experience anxiety. It’s the physical response to fear which has kept us safe over the course of evolution. These physical feelings can range from nervousness up to extreme panic or sheer terror.

The fight, flight or freeze response

When we are exposed to a threat (whether physical or psychological) we experience a fight/flight/freeze response where adrenaline is released into our bodies and causes a series of physiological changes.

Anxiety tells us that there is something dangerous to pay attention to. This is why it feels so unpleasant: it gets our attention. Often this is a helpful response – for example, if a car was speeding towards us and we felt no anxiety we would be more likely to get injured or killed. Anxiety can also help improve performance; for example it can help athletes to perform better during a race.

However, in some situations this anxiety response becomes out of proportion to the event and is less adaptive, for example freezing during an exam or in a social situation.

It can be helpful to imagine the graph below – some anxiety will improve your performance, however too much anxiety will impair your performance.

Physiological response to stress

When the fight/flight/freeze response is activated we experience an increase in adrenaline which causes a number of physiological responses. Whilst these can feel unpleasant, they all serve a specific protective purpose and are signs that your body is preparing to fight, to run away or to freeze until the threat passes.

1. Glucose is released into your blood stream to give you a surge of energy.

2. You will breathe faster in order to increase your oxygen intake, which is needed to convert the glucose into energy. You may start to yawn, notice breathlessness or tightness in your chest, or experience dizziness.

3. Your heart beats faster to carry the extra oxygen in the blood to your muscles and your brain. It may feel like your heart is pounding.

4. Your skin, fingers or toes may tingle or feel cold as blood is diverted away from areas that are not so vital.

5. You may experience a dry mouth or a churning stomach as blood is diverted from your digestive system to your muscles in preparation for action.

6. Your muscles may tense for action which can result in aches and pains, trembling or shaking.

7. You may sweat more, which helps to cool you down. There is also an evolutionary theory that sweating made us more slippery in order to escape from predators.

8. Your vision may change as your pupils dilate to take in more information about your environment.

Reducing the physical symptoms of anxiety

As we saw in the vicious cycle, how you feel physically can have a big impact on both your thoughts and what you do. Reducing these physical reactions can help to improve how you are feeling overall.

Practising relaxation on a regular basis can help lower levels of physical tension in the long term, but these relaxation techniques could also be useful before an exam to reduce physical stress.

Anxiety and breathing...Anxiety can cause your breathing rate to increase and often involves taking deeper breaths in. This disturbs the balance between oxygen and carbon dioxide in the body. It can lead to feeling dizzy, light-headed, and feeling like it’s difficult to breathe. Sometimes you might try to breathe more, which unfortunately increases these symptoms and the feelings of anxiety.

Over breathing is not dangerous, but it can make you feel more on edge. Some people may feel like they are going to faint due to the dizzy, light-headed feelings they experience. However, these two physiological processes are very different. When we faint, it’s due to low blood pressure, and we faint so that we become horizontal and blood can flow freely to the brain – it’s another type of survival mechanism. On the other hand, when we feel anxious, our blood pressure is higher due to our increased heart rate, and although we feel dizzy and light-headed, this is due to increased oxygen intake and not low blood pressure. Nobody has ever fainted from increased breathing when anxious.

Relaxation: An exercise in controlling your breathing

By controlling your breathing and slowing down you can re-balance the oxygen and carbon dioxide levels in your brain and can reduce feelings of dizziness and light-headedness.

l Make sure you are sitting comfortably

l Breathe from the abdomen, not the chest (you can check this by placing a hand on both – which one rises?)

l Take a breath in for 4 seconds

l Hold it for 2 seconds

l Then breathe out for 6 seconds

l If this is too hard to start with try breathing in for 2 seconds, holding it for 1, and breathing out for 4.

Anxiety and tension

We often tense our muscles when we feel anxious. This can make us feel more on edge, and can cause our muscles to ache and feel sore.

We may end up feeling drained and exhausted from holding this tension as it wastes energy, which we means we have less to spend on other things. Tension headaches may also occur. All in all, feeling tense and on edge means that we are more reactive to things happening around us, even if they wouldn’t normally cause us stress. Relaxation techniques that reduce muscle tension can therefore be really beneficial in tackling anxiety.

Relaxation: Releasing tension

A technique that can help to reduce tension is progressive muscle relaxation. This involves tensing and relaxing all the main muscle groups. Before attempting this exercise, consider:

l Any injuries (be careful of tensing)

l Have a relaxing environment free from distractions

l Don’t do this after a big meal or after drinking

The general ideas of Progressive Muscle Relaxation are below; on the next page are detailed instructions guiding you through how to tense all the main muscle groups.

l Tense the muscle but not so much that you feel any pain

l Hold the tension for about 2 seconds then relax the muscle for about 5 seconds

l Sometimes saying ‘relax’ when releasing the muscle is helpful

l When relaxed let the muscle go limp – feel the weight in the muscle

l Really tune in to the sensation of the tension leaving your muscles.

Progressive muscle relaxation sequence

1. Right hand and forearm. Make a fist with your right hand.

2. Right upper arm. Bring your right forearm up to your shoulder to “make a muscle”.

3. Left hand and forearm. Repeat as for right hand and forearm.

4. Left upper arm. Repeat as for right upper arm.

5. Forehead. Raise your eyebrows as high as they will go, as if you are surprised by something.

6. Eyes and cheeks. Squeeze your eyes tight shut.

7. Mouth and jaw. Open your mouth as wide as you can, as you might when you‘re yawning.

8. Neck. Be careful as you tense these muscles. Face forward and then pull your head back slowly, as though you are looking up to the ceiling.

9. Shoulders. Tense the muscles in your shoulders as you bring your shoulders up towards your ears.

10. Shoulder blades/back. Push your shoulder blades back, trying to almost touch them together, so that your chest is pushed forward.

11. Chest and stomach. Breathe in deeply, filling up your lungs and chest with air.

12. Hips and buttocks. Squeeze your buttock muscles.

13. Right upper leg. Tighten your right thigh.

14. Right lower leg. Do this slowly and carefully to avoid cramps. Pull your toes towards you to stretch the calf muscle.

15. Right foot. Curl your toes downwards.

16. Left upper leg. Repeat as for right upper leg.

17. Left lower leg. Repeat as for right lower leg.

18. Left foot. Repeat as for right foot.

Practice means progress. Only through practice can you become more aware of your muscles, how they respond with tension, and how you can relax them. Training your body to respond differently to stress is like any training – practising consistently is the key.

Relaxing ‘safe place’ imagery

The effect that mental images can have on our physiology is amazing. Just take a minute to imagine your favourite meal: how it would look, the aroma, the texture as you take the first mouthful and the delicious flavours. Now, what do you notice happening? Do you have increased saliva in your mouth, or a rumbling in you stomach? The images we have in our minds have a direct impact on how we feel and our physiology. With this in mind, practicing relaxing imagery exercises can be really helpful at calming the body and mind.

l Start by getting comfortable in a quiet place where you won’t be disturbed, and take a couple of minutes to focus on your breathing. Close your eyes, become aware of any tension in your body, and let that tension go with each out breath.

l Imagine a place where you can feel calm, peaceful and safe. It may be a place you’ve been to before, somewhere you’ve dreamed about going to, somewhere you’ve seen a picture of, or just a peaceful place you can create in your mind’s eye.

l Look around you in that place, notice the colours and shapes. What else do you notice?

l Now notice the sounds that are around you, or perhaps the silence. Listen for sounds that are far away and those nearer to you, those that are more noticeable, and those that are more subtle.

l Think about any smells you notice there.

l Then focus on any skin sensations – the earth beneath you or whatever is supporting you in that place, the temperature, any movement of air, anything else you can touch.

l Notice the pleasant physical sensations in your body whilst you enjoy this safe place.

l Now whilst you’re in your peaceful and safe place, you might choose to give it a name, whether one word or a phrase that you can use to bring that image back, anytime you need to.

l You can choose to linger there a while, just enjoying the peacefulness and serenity. You can leave whenever you want to, just by opening your eyes and being aware of where you are now, and bringing yourself back to alertness in the ‘here and now’.

www.getselfhelp.co.uk/imagery.htm www.get.gg © Carol Vivyan 2009, permission to use for therapy purposes

Sleep problems

Sleep problems are really common, and most people will have problems with their sleep at some point in their lives.

Being at university can also make sleep more difficult, as the student lifestyle can mean it’s harder to keep a routine and stick to healthy sleeping habits. A lot of people who experience anxiety have problems with not sleeping enough, or sleeping too much, which can then make everything seem that much harder.

There are four main types of sleep problem:

l Falling asleep

l Staying asleep

l Non-restorative/light sleep

l Waking up too early

Problems with sleep can form part of the vicious cycle of anxiety, as if we are feeling tired or groggy then we are more likely to worry about things and feel as if we are unable to cope.

Preparing for sleep…

It is really important to allow yourself time to wind down after each day, as otherwise your body and mind will still be active when you try to sleep. Without wind-down time you may end up lying in bed with loads of thoughts going through your head.

Wind-down time should last at least an hour. During this time try to do relaxing and enjoyable things, and avoid all university work or anything that makes you feel stressed. Doing the same thing each night can help your body to recognise triggers that suggest it will be time to sleep in an hour.

How to improve your sleep: lifestyle habits

Another way to improve sleep is to look at the things you could improve in your lifestyle. Below are some examples of different things that might influence your sleep.

Reduce alcohol

Alcohol interrupts the quality of sleep a person has and can cause more waking in the night. It can also lead to tiredness in the day.

Earlier dinners

Going to bed full up or hungry can interfere with sleep, and so it’s best to have an early dinner, and a light snack before bed if needed.

Reduce nicotine and caffeine

Nicotine and caffeine are both stimulants and can interfere with getting to sleep. Try to avoid them for up to 4-6 hours before going to bed.

Increase exercise

Physical activity is great for improving sleep, but try to avoid it for up to 4 hours before bed time.

Same routine

Getting up at the same time each day is one of the most important things you can do to improve your sleep, even if you haven’t slept much the night before!

GOOD SLEEP

I’m going to change:

How to improve your sleep: environmental factors

Another way to improve sleep is to look at what you might be able to change in your environment. Below are some examples of environmental factors that might influence your sleep.

What could you change in your bedroom that could help your sleep?

Low noise levels

Ear plugs can be good for blocking out noise.

Right temperature

If you’re too hot or too cold this will interfere with falling asleep. It is important to have the right duvet – the ‘tog’ will indicate how thick it is.

Improve air quality

Central heating can cause stuffiness and poor air quality which can make it harder to fall asleep.

Increase darkness

You can buy ‘black out’ curtains that block a lot of light, or an eye mask. If it’s light then your brain is getting the message that it’s day time and that you should be asleep.

Decrease any discomfort

‘Topper’ mattresses are good for improving the comfort of your bed, and they are usually quite cheap.

Avoid TV and computers before bed

Electronic screens are overly stimulating for the brain due to the visual stimulation. They can make it harder to fall asleep.

GOOD SLEEP

I’m going to change:

Four rules for better sleep

The association we have between our bed and sleep can make a big difference to how easily we fall asleep. If we often lie in bed worrying and struggle to get to sleep we might start to associate the bed with stress, rather than calmness and sleep. The longer we spend in bed awake, the weaker the association will be with sleep. Below are four different rules to strengthen the association between bed and sleep.

The bed is for sleep rule

Everything else (except sex) is banned! So no reading; working; talking on the phone; looking at the internet - nothing in bed but sleep. Sometimes this might be difficult due to the student lifestyle, but it’s worth doing if sleep is a problem.

The 20 minute rule

Healthy sleepers generally fall asleep within 20 minutes. If you are lying in bed unable to get to sleep for longer than this then the association between bed and wakefulness and anxiety is strengthened. If you’re not asleep within 20 minutes, get up, go into a different room if possible and do something relaxing until you feel sleepy again, then go back to bed.

The sleepy rule

Feeling tired and feeling sleepy are different. You can actually feel tired without feeling sleepy but you should only try and go to sleep when you feel sleepy. When you feel sleepy you might yawn a lot, have hot, heavy eyes that feel like they want to close and have heavy muscles.

The night time rule

Only sleep at night. Make sure not to nap in the day, no matter how much sleep you missed the night before. Napping in the day decreases the need to sleep at night and gets rid of the ‘sleepy’ feeling you need to fall asleep at night.

About negative thoughts

I can’t cope.

I’m going to fail!

Other people are doing so much better than me.

People must think I’m stupid.

When feeling anxious, negative thoughts and worries are very common. We may think negatively about ourselves, others, and current situations as well as the future – these thoughts only make us feel worse. It’s part of the vicious cycle that we can get trapped into. Challenging these thoughts is another way of breaking the cycle.

Anxious thought

‘I’m going to fail this exam’

Physical response

Faster heart rate and breathing

Characteristics of unhelpful thoughts

Automatic: We don’t think them on purpose; they come into our minds involuntarily.

Believable: They seem real at the time.

Unhelpful: They are the kind of thoughts that would be upsetting to anybody.

Distorted: They are not accurate reflections of reality but based on how we feel at the time.

Unhelpful thinking styles

Have a look through the thoughts you have recorded and see if any of these thinking styles apply, these can be helpful to refer to when trying to generate evidence.

All or nothing thinking (sometimes called ‘black and white thinking’)

Seeing only one extreme or the other. There are no in-betweens or shades of grey.

Over-generalising

Seeing a pattern based upon a single event or being overly broad in the conclusions we draw. Tends to involve the words always, everyone, never.

Magnification and minimisation

Blowing things out of proportion (catastrophising), or inappropriately shrinking something to make it seem less important.

Mental filter

Only paying attention to certain types of information such as noticing failures but not successes.

Disqualifying the positive

Discounting the good things that have happened or that you have done.

Compare and despair

Seeing only the good points in others compared with the bad ones in yourself.

Jumping to conclusions

Mind-reading

Assuming we know what someone else is thinking.

Fortune telling

Predicting what’s going to happen in the future.

Emotional reasoning

Assuming that because we feel a certain way what we think must be true.

Shoulds and musts

Putting unreasonable demands or pressure on yourself or others. Using critical words which make us feel guilty or like we have failed.

Personalisation

Blaming yourself or taking responsibility for something that wasn’t completely your fault or blaming other people for something that was your fault.

Labelling

Assigning labels to ourselves or other people.

Memories

Current situations triggering memories of past upsetting events.

Thinking styles quiz

John has just received a piece of coursework back; the grade was what he wanted but he only focuses on the feedback saying he needs to be more critical. He feels terrible about this and starts to think that he is not that good at writing essays. He starts to remember other times when he did not do well at essays, and thinks ‘I should do better.’ He starts to worry about what his tutor will think of him.

Thinking styles:

Sally sees her friend Kate at the top of the stairs in the Forum. She waves but Kate doesn’t wave back. Sally thinks, ‘Kate doesn’t like me anymore, she’s ignoring me. I must have done something to upset her. I’ve never had many friends – I guess I’m just not very likeable.’ Later on that day she doesn’t text Kate about going out for a drink.

Thinking styles:

Beth has just started university, and she’s made some friends in her halls but is very nervous and worries about what other people will think of her. When she hears about a social with people from her course she thinks: ‘I can’t go to the pub with the people from my course. They will see how nervous I am. No one will talk to me and I will be all on my own and look silly.’

Thinking styles:

Tony is about to give a presentation and notices that he feels nervous. He thinks ‘this is going to be terrible. My mind will go blank, my throat will dry up and I won’t be able to say anything. I’ll make a complete fool of myself, it’s going to be so embarrassing. I bet this will affect my mark too.’

Thinking styles:

Cognitive Restructuring: Challenging your thoughts

Cognitive Restructuring is a technique that aims to change unhelpful thoughts by identifying and challenging them.

This technique can help you to see situations in a more objective and balanced way. It does this by using questions to help you consider different perspectives and generate factual evidence to challenge your unhelpful thoughts.

Challenging negative thoughts can be difficult at first, but over time it gets easier and easier.

The three steps of Cognitive Restructuring

1

2

3 Recording your thoughts in a Thought Diary Revising your initial thought

Looking at evidence for and against your thoughts

Recording your thoughts

Firstly, you need to identify the content of your unhelpful thoughts. Each time you notice yourself feeling anxious, complete the initial three columns of the Thought Diary sheet.

l In the first column write down a brief description of the situation you were in when the thought occurred i.e. where you were and what you were doing.

l In the second column write down one emotional word to describe the feeling you had as a result of the thought, such as sad, anxious, or angry. Also rate how bad that feeling was on a scale of 0-100%.

l In the third column write down exactly what the thought was i.e. the words that went through your mind or the image that occurred. Then rate how much you believe that thought to be true, where 0 is not at all and 100% is totally believe the thought.

l For the time being, ignore the last two columns; we return to complete these in the final stage of the process. It is suggested you collect your thoughts in this way for one or two weeks, depending on how frequently unhelpful thoughts are occurring for you.

Sally spent a week noting down unhelpful thoughts as they arose. An example of one of her thoughts is detailed below...

Situation:

Where you were and what you were doing

In the Forum

Waved to Kate but she didn’t wave back

Feeling: Emotion experienced and rating of how bad it was (0–100%)

Worried (70%), anxious (60%)

Thought: Words that went through your mind and rating of how much you believe this thought (0–100%)

I have done something to upset her (65%)

Revised thought: Words of new thought and rating of how much you believe this thought (0–100%)

Feeling: Emotion experienced and rating of how strong it was (0–100%)

Worksheet A Thought diary

Situation:

Where you were and what you were doing

Feeling: Emotion experienced and rating of how bad it was (0–100%)

Thought: Words that went through your mind and rating of how much you believe this thought (0–100%)

Revised thought: Words of new thought and rating of how much you believe this thought (0–100%)

Feeling: Emotion experienced and rating of how strong it was (0–100%)

Challenging your thoughts

Next you examine your thoughts in an objective way. You can do this by collecting evidence for and against a particular thought to see whether it is accurate or not.

Choose a frequent thought from the ones you have noted on your diary sheet. Write the thought down in the top left corner of the Evidence Table sheet on page 26 and note the percentage belief rating in the top right box.

Then, imagine that you are the judge in a court where the evidence for and against the truth of your thought is being examined. Write down the evidence for each side in the table. Remember that the evidence should be factual and that you need to present the full picture so that a fair decision can be made. Generating the ‘Evidence Against’ can be difficult as it is something you a probably not used to doing. Some questions to help you to do this are given on the next page.

Next Sally chose one of her thoughts and considered the evidence for and against it...

“I have done something to upset her”

She did not wave to me

She cancelled our lunch the other day

I saw her yesterday and we were fine and had a good time

She never said anything about me upsetting her

In the past when I have upset her she told me straight away

We have plans tomorrow and she hasn’t cancelled them

Her parents are in the middle of a break up, she has got a lot on her mind

Generating evidence against your thoughts

It can help to imagine that you are a judge in a court house and that evidence needs to be presented for and against the thought.

In court cases the evidence provided needs to be factual and concrete, and it is exactly the same for the evidence here. We want to get to the bottom of whether your thought is based on the facts or whether it’s based on how you feel.

It can be really difficult coming up with concrete evidence to start with, particularly against the thought as you may be more in the habit of looking for evidence to support your negative thoughts! Below are some tips for generating evidence.

What alternative views are there?

l If you rate the belief in your thought as 75%, what makes up the remaining 25%?

l How would a friend or someone who cares about you view this situation?

l How would I have viewed this situation before I felt anxious?

l How would I view someone else in my situation?

Does this thought fit with any of the thinking styles on page 18?

l If it does then this means you are only looking at this from one perspective, what is another perspective?

l For example, if you notice the thought fits into a ‘self blaming’ style of thinking then write down all of the other external factors which might have been involved in this.

What action could I take?

l Am I assuming I can do nothing to change my situation?

l Am I overlooking solutions to problems on the assumption they won’t work?

Are there any good reasons to be so worried?

l Have you been wrong about similar things in the past?

l Will this problem matter in a week, month or year?

Revising your initial thought

Finally, you reconsider the original thought, taking all the evidence into consideration to put it into perspective. Try to come up with a revised thought based on both sides of the argument.

l Write down the new thought in the fourth column of the Thought Diary and rate how much you believe it.

l In the final column re-rate your feeling using the same 0-100% scale. Notice if your emotion has changed as a result of changing your thought.

l Remember, unhelpful thinking takes time to change; it may often be necessary to challenge your thoughts several times before you notice a difference in how you feel. As you become more experienced in this approach you will start to find that the process becomes more automatic and you are able to catch the thoughts and judge them as they actually happen.

Finally Sally looked back at her initial thought and, considering all the evidence she had noted both for and against the thought, came up with the following alternative thought...

Revised

thought

What is your new more balanced thought? How much you believe this thought (0-100%)?

“She has a lot on her mind and probably didn’t see me” (50%)

Feeling

Re-write the emotion you had previously. State how strong the emotion is when you have your new thought (0-100%)

You can think about thoughts like pathways in a field: the more you have a thought the more entrenched the path becomes, until it becomes the automatic route you take. By challenging these thoughts, you are stopping yourself going down that automatic path and instead you are creating a new path. This might feel strange at first because you have not used this path before (or thought in this way), but the more you use it and the less you use the old path (or thought), the more entrenched it will become and the more ‘overgrown’ the old path will feel. Eventually the new way of thinking will be the one which you automatically go down.

Worksheet B Evidence table

Problem solving

There may be specific problems that you are worrying about or that are making you feel anxious. These problems can feel overwhelming and it can feel impossible to find a solution. The following problem solving technique can help you to think through the problem in a step by step way and hopefully come to a practical solution. This might also be a helpful technique to use if you find you have more evidence for a negative thought than against it. If the thought is based on the facts then it is more helpful to think about what can be done to overcome this problem rather than simply changing how you think about it.

Seven steps to problem solving

1. Problem identification – What is the specific problem?

2. Solution identification – What are all the potential solutions? Even those that sound absurd!

3. Strengths and weaknesses analysis – What are the strengths and weaknesses of each solution?

4. Solution selection – Which solution is the best?

5. Implementation plan – Plan what, where, when and who?

6. Implementation – Carry out the planned solution

7. Review – Review the original problem. Has this made a difference?

Worksheet A Problem solving

Step 1: Problem identification (write your problem here)

Step 2: Solution identification (write down as many different solutions as possible – use additional sheets if necessary)

Step 3: Strengths and weaknesses analysis (write down the advantages and disadvantages of each solution using Worksheet B on the next page)

Step 4: Solution selection (choose one solution)

Step 5: Implementation plan (write down the steps you will take to apply your chosen solution – use additional sheets if necessary)

Step 6: Implementation (carry out the plan)

Step 7: Review (write down how the plan went)

Worksheet B Problem solving: Strengths and weaknesses analysis

Noticing the positives

When we feel anxious sometimes we pay more attention to the negative or stressful things that happen to us each day.

Noticing and remembering the positives is a way of trying to re-balance our attention and improve our mood. Before going to bed write down five things that happened that day that were positive – they can be anything, however big or small. This can also help to put you in a more positive mind set which might mean falling asleep is easier.

Five positives from my day

1. Not getting stuck in the rain on my way home

2. Having a nice chat with my Mum

3. The view from the top of the hill

4. The gingerbread latte from Costa

5. My favourite song was played on the radio

How to manage worry

Often when we feel anxious we tend to worry a lot more, but worrying can also make us feel more anxious and on edge. This contributes to the vicious cycle. Everybody worries from time to time and it can help us to solve problems and consider different options, however sometimes we can get caught in a cycle of worrying that doesn’t solve any problems and only leads to us feeling more anxious.

Worry time can be helpful when you notice that the same worries keep going round and round in your head and you are not able to control them. Often these worries make you feel more anxious and when we try and stop ourselves from worrying what tends to happen is that we worry even more. Trying to not think about something just doesn’t work, and worry time is a way of giving limited time to worrying, so we are not just trying to block it out but we are containing the worry so it does not impact so much through the day.

l Whenever you notice a worry write it down (make a list)

l Give yourself a set amount of undisturbed time each day to go through your list

l Separate practical worries (problems that you can do something about) from hypothetical worries (‘what ifs’)

l Write an action for all practical worries (what, when, where and who?)

l Give yourself time to think about the hypothetical worries (not right before going to bed)

l Once the time is up you need to stop worrying and focus on something else

l You might want to screw the paper up

l Try and do something engaging and get a change of scenery

l Write down any worries that you have outside of your worry time and think ‘I will think about that tomorrow during my worry time. There is no need to worry about it now’

l When in bed, try to focus your attention on your breathing: in-out, in-out

l Notice when your mind wanders and bring your attention back to your breathing or do something engaging where it is difficult to worry

What keeps anxiety going?

We have looked at how changing thoughts can reduce anxiety, and now we are going to move on to look at behaviour.

These few pages give an idea of the types of things that we do which contribute to our anxiety and maintain the cycle of anxiety.

Avoidance/escaping...

l We have a natural tendency to avoid feared situations or objects (flight)

l Avoiding situations reduces anxiety quickly in the short-term

l If you avoid a situation once, this increases the likelihood of avoiding it next time

l This leads to a vicious cycle of avoidance and anxiety

It is completely understandable that you would want to avoid the situations that trigger your anxiety; after all the fight or flight response is telling you that this is a dangerous situation. But by avoiding these situations it does mean that the next time you’re confronted with the same situation you are going to feel just as anxious as before, or maybe even more so. Avoiding certain situations may also start to have a negative impact on your life which can make you feel worse.

Safety behaviours

When we feel anxious it is natural to want to do whatever we can to feel better. Often we will still go into the situations that make us feel anxious, however we will do certain things to reduce the anxiety, for example playing with our phone at a party if we are worried about not having people to talk to.

We call these things safety behaviours. They are behaviours that make you feel safer and therefore less anxious. However, they also prevent you from gaining the valuable experiences that will help you overcome your anxiety. They also mean that you start to rely on them and feel that you would not have coped if you hadn’t used the safety behaviour.

Going to a party

I will not have anyone to talk to. Everyone will see me standing on my own.

Going to the supermarket I might collapse.

Attending a tutor group meeting

Crowded areas

Giving a presentation

If I get something wrong people will laugh at me.

I will not be able to escape if I need to.

Everyone will see that I am going red, they will judge me.

Stay close to a friend all night, and pretend to go out and use phone when they go to the toilet.

Not letting go of the trolley.

Sit at the back, keep quiet, only talk about things you are confident about, avoid eye contact.

Stay close to the exits.

Wear more foundation to cover it up.

Situation

Thoughts or risk

Safety behaviour

Tackling negative predictions

When we feel anxious, it is common to make negative predictions about what’s going to happen in the future.

Predicting the worst tends to lead us to engage in unhelpful behaviours such as avoidance and reliance upon safety behaviours. By avoiding situations or always using safety behaviours we are never able to test our predictions and find out what actually would have happened in that situation. If the outcome was different to what we predicted this could really help to break the cycle of anxiety. Behavioural experiments are a good way of testing negative predictions in a systematic way.

Testing predictions: The process

We can test our negative predictions by following the steps detailed below:

1. Note down the thought or belief you wish to test and rate how strongly you believe this

2. Note an alternative prediction or belief and rate how strongly you believe it

3. Design the experiment – What will you do to test the prediction? Where? When? For how long? With whom?

4. Consider any safety behaviours that would need to be dropped

5. Consider likely problems and how they could be overcome

6. Note the outcome

7. Note what you’ve learned and re-rate the belief in the original prediction

Sally’s example

Sally feels nervous in social situations; she tends to go to events where she knows everyone, or goes with one friend that will stay with her all night.

She thinks she will not have anything to say to someone she does not know and that they will be bored and leave. If she goes to an event where she doesn’t know many people and her friend goes to the toilet Sally will find somewhere quiet and play on her phone until she comes back. She will often make up excuses for not going to such events, like having a deadline the next day or feeling too tired.

What are the thoughts and behaviours that are feeding into Sally’s vicious cycle of anxiety?

Testing negative predictions: Sally’s example

Step 1: Negative thought or belief to be tested How much do you believe this prediction?

If I talk to someone I don’t know well when out socially I will clam up and have nothing to say 90%

Step 2: What is an alternative prediction? How much do you believe

I will feel nervous but will be able to maintain a conversation

Next time I go out to the pub I will try speaking to a friend of a friend who I don’t know well for at least 3 minutes

Step 4: What safety behaviours would you need to drop?

Staying with people I know well, playing on my phone to avoid conversation

Step 5: What things may get in your way? How will you overcome these?

There may not be a naturally occurring opportunity to do this and I may need to instigate conversation or arrange the scenario with a friend

Step 6: Record what happened when you carried out the experiment

I was nervous and paused for a few seconds once or twice but I managed to think of things to say and keep the conversation going

Step 7: What can you learn from this? How much do you believe your original prediction?

Although I am nervous in conversations with people I do not know well, I can maintain a conversation. Belief I will clam up – 50%

Analysing the results: Sally’s example

From the behavioural experiment Sally found that she could cope with meeting new people better than she originally predicted. She started to attend more social events, and she even pushed herself to go to a society social without her friends. She found that she enjoyed this and now goes each week.

But what if my original prediction is supported by the findings of the experiment?

A. Is there another explanation for what happened?

For example, if Sally found it difficult to drop her safety behaviours and she sat in the corner and avoided eye contact with anyone then this could have been the reason no one came over and spoke to her.

B. What else was happening at that time?

For example, did Sally have anything else going on which might have affected the outcome? She might have been ill that night or she might have had a deadline the next day.

C. Are there other ways of viewing what happened?

How would someone else view this outcome? What would a friend say about this if you talked them through it?

D. What could I learn from the experience to improve or change things in the future?

If there were certain things which affected the outcome, then how can you stop this from happening again in the future? Were there any other safety behaviours that you noticed that you could try and stop next time?

Behavioural experiment worksheet

Avoidance, escaping and anxiety

As we saw from the vicious cycle of anxiety and safety behaviours, how we respond to situation can be a strong factor that maintains anxiety.

The fight or flight response tells us that there is something dangerous to respond to, so it’s only natural that we would want to escape or avoid the perceived threat. However, when the threat isn’t physical, escaping or avoiding it can actually maintain the vicious cycle of anxiety.

Sally: I feel really anxious when I’m in big open spaces where there are lots of people. All I think is ‘I need to get out of here,’ and I try and leave as fast as possible or avoid open spaces all together if possible.

The Escaping graph shows what happens to your anxiety when you avoid and escape a feared situation. For Sally this would show her experience of going into the Forum at lunch time. When she enters the Forum her anxiety peaks really quickly. This feels so horrible that Sally gets out of there as fast as she can. When she leaves the Forum she experiences huge relief as her anxiety level drops. What she then remembers is the anxiety she felt in the Forum and the relief she felt when she left.

The Escaping and Anxiety graph shows how over time avoiding and escaping the feared situation can actually increase anxiety. The graph to the right shows that when you escape a feared situation all you remember is how horrible you felt when you were in the situation and how relieved you felt when you got away. This means the next time you are in the same situation, the anxiety is worse than before and the desire to get away is even stronger. This is how phobias develop. Avoiding the situation means that although we escape the anxiety temporarily, the situation will continue to trigger a strong reaction.

Escaping and anxiety

Tackling avoidance to overcome anxiety

Research has found that by tackling avoidance in a gradual, controlled, and systematic way you can dramatically reduce the anxiety associated with a particular situation or object. This technique is called ‘exposure therapy’. The idea of this may sound scary but we will go through how the process can be broken down to make it manageable. The graphs below show how exposure therapy works.

The vicious cycle of anxiety can be broken by exposure to the feared situation. If we remain in the situation without escaping or distracting ourselves, our anxiety will start to come down on its own as our adrenaline response reduces. This process is called habituation. We then need to repeat this process for the initial feeling of anxiety to reduce each time. The initial anxiety we experience and the time it takes for us to habituate should decrease with each exposure.

Often when we face a situation that makes us feel anxious we try and make ourselves feel safer by distracting ourselves or doing certain things to reduce the anxiety. Although this can help in the short term, it also brings our attention back to the belief that the situation presents a threat. The fight or flight response then continues rather than reduces. Many people have tried to face their fears, however unless we experience the anxiety (as horrible as it can be) we won’t habituate. If we distract ourselves the next time we are in the situation our anxiety will be as high as it has been previously.

To make exposure more manageable it can be approached in a gradual, graded way. Facing situations that cause you anxiety can be a really difficult thing to do.

Four principals that make exposure effective

1. Graded

Rank activities according to the amount of anxiety provoked by the object or situation, starting with the least difficult and finishing with the hardest. Then plan exposure exercises in a graded way using the activities on the list. For exposure to be effective you need to experience the anxiety reducing whilst you are in the situation. For this to happen you need to expose yourself to situations which cause you at least 60% anxiety when you first go into them. The higher up the list you can start, the quicker you will break the cycle of anxiety.

2. Prolonged

You need to remain in the situation until your anxiety has reduced by at least half. The time this takes can vary from person to person; you should initially allow yourself a few hours for exposure exercises. Your anxiety will reduce more quickly with each exposure exercise. If you don’t stay in the situation long enough for your anxiety to come down then you won’t feel a reduction in anxiety the next time you are in that situation. If anything it might even be worse.

3. Repeated

You also need to repeat the same exercise 3-5 times a week, as the more you do it the quicker your anxiety will come down in that situation. Each time you repeat it you should notice a decrease in the initial anxiety you feel until you no longer find the situation fearful. Once your anxiety before you go into the situation is reduced by at least 50%, you can move onto the next activity on your hierarchy.

4. Without distraction

You need to fully feel the sensations of anxiety rather than distracting your mind from it or by doing things which make you feel safer. If you distract yourself then you will notice an effect similar to that shown on the distraction graph. Rather than your anxiety reducing over time, you are constantly reminding yourself that the situation presents a threat and not learning that your anxiety will come down on its own, without doing anything else. It also means that the next time you are in that situation your anxiety will be just as high, rather than reducing. Distracting yourself from the anxiety keeps the vicious cycle going!

Creating a hierarchy: Making it graded

Sally created a hierarchy for the situations that make her anxious which you can see below.

First, she noted down the situations that caused her anxiety, then she identified which situation she would find most difficult and which she would find least difficult. Finally she put these into her hierarchy sheet and rated how anxious each situation would make her feel.

It helps to consider nuances in the situation which affect your anxiety level, for example who is around at the time, how far you are from the feared object or activity, and whether the time of day makes any difference. For Sally, the Forum and town were more difficult when they were busier at lunch time and on weekends.

Your hierarchy

Note down all the situations or objects which make you feel anxious. Start with the most difficult and work towards the least difficult. As we said before, be sure to consider nuances in the situation which affect your anxiety level, such as who is around at the time, and how far you are from the feared object or activity.

Setting up exposure exercises

Its really useful to plan exposure exercises on a weekly basis starting with the activity on the hierarchy that you feel able to do. Plan when to carry out the exercises in advance. Rate anxiety as a percentage before (when you start to prepare for the exercise, for example getting your coat or bag to go out), at the start (when you are in the situation) and at the end of the exercise (when your anxiety has reduced by half). Leave the duration box blank initially and fill this in after finishing the exercise with how long it took for your anxiety to reduce by at least half.

Sally decided to start exposure by walking a different route back to her halls, as she felt she would be able to manage this. At the start of the week she planned in a few exposure exercises, including what she was going to do, when she would do it and where it would take place. She then started to complete the exercises and recorded what happened to her anxiety on the exposure exercise worksheet. She could see from her ratings that her anxiety did reduce when she repeatedly walked a different route home.

REMEMBER: You need to stay in the situation until your anxiety at the start of the exercise reduces by half, but the larger the reduction in anxiety, the easier it will be next time and the quicker the exposure process, so the longer you can stay in the situation the better!

Exposure exercise worksheet

Staying well

Well done on getting to the end of Anxiety Busting! It can be helpful to look back over the weeks you have been working on these techniques and think about what has been the most helpful. There is no way of knowing if anxiety will be a problem for you again in the future, but hopefully working through this booklet has equipped you with some ways of coping if you do feel that way again.

What have you learnt?

Which techniques have worked best for you?

What are your signs of anxiety? (Thoughts/feelings/behaviours)

What areas are you going to work on?

What techniques will you use to do this?

Setting yourself goals to work towards...

Sometimes it can be really helpful to think about what you want to continue working towards in the near future.

There might be things that you have made a good start on whilst working through Anxiety Busting, or maybe there are other areas of your life where you feel setting a goal would be helpful. Either way, having a clear goal that you can measure and assess can really help you have a clear direction. It may also be helpful to give yourself one day a week or a month to look through this booklet again and to re-assess where you are with achieving your goals.

(circle a number)

GOAL ONE:

GOAL

Well done for working through Anxiety Busting!

It is worth keeping an eye on how you feel as it is perfectly normal to experience anxiety sometimes, but we also know that anxiety problems can return. If you find that you have been feeling anxious for a while then you should try to do something about it. The important thing is that you have now learnt some skills that you can use to keep yourself feeling well, and to tackle any anxiety if it does return.

You might feel as though you’re still not where you want to be in terms of your anxiety. This is completely normal, as it can take time for these techniques to reverse the vicious cycle of anxiety. If you have found that they have made any difference at all, even if it’s small, this is encouraging.

Just keep up the good work and as time goes on you will notice it getting easier. Further Cognitive Behaviour Therapy might also be helpful.

It can be helpful to schedule in one day a month where you can focus on YOU! You can have a look back through this booklet to remind yourself of the different techniques, and focus on activities that are enjoyable and don’t involve any stress. If you schedule it in you’ll be more likely to do it, as these things can easily get lost or forgotten about otherwise.

Emergency support services

It is relatively common when people are going through difficulties to have thoughts that they would be better off dead or to hurt themselves in some way. These may just be brief passing thoughts or reflect a sense of feeling trapped, but without any intention to do anything.

On the other hand, some people find themselves thinking about death a lot, or having thoughts about ending their lives. They may have even had thoughts about how they might kill themselves or have made a plan to end their life. If any of these cases are true for you, we strongly urge you to talk to someone about these thoughts.

If you are having suicidal thoughts, please contact one of the services listed below. These services are available to help you during this difficult period.

During office hours you can contact...

Your GP to make an urgent appointment with a doctor. In an emergency, the GPs at the Student Health Centre on Streatham Campus can also see students who do not have a GP in Exeter.

Out of hours you can contact...

If you are in Exeter: You can phone the NHS Urgent Mental Health Line, available 24/7 on 111. You will be able to speak with a mental heath professional and gain advice on the best course of care.

If you’re not in Exeter: You can find your local Urgent Mental Health Line by visiting the NHS website: nhs.uk/service-search/mental-health/find-an-urgent-mentalhealth-helpline

The Samaritans: A confidential service and support for anyone in crisis. Call 116 123 or visit samaritans.org

A&E You can also attend A&E for emergency support at any time.

Jenny Cadman, Sarah Lane and Josie Bannon

(Psychological Wellbeing Practitioners)

Wellbeing Centre

University of Exeter